Journal o/ Community Psvcholoey, 1978, 6, 381-392.

POLITICAL-ECONOMIC AND PROFESSIONALISTIC BARRIERS TO COMMUNITY CONTROL OF MENTAL HEALTH SERVICES:

A COMMENTARY ON NASSI* PHIL BROWN

University of MassachusettslBoston

Nassi (1978) described the limits of community control in community mental health centers. This problem can be further understood by exploring the growth of professional dominance and psychiatric ex ansionism in the 1960s. One consequence was a ‘social movement’ ideology whict psychologized political and economic phenomena, while actual1 opposing any effective mobilization for community con- trol. Professionals have rargely remained unaware and/or unresponsive to these tendencies. Likewise, the have failed to grasp the system of chaos which characterizes mental h e a d policy in the U. S. Mental health care is increasingly falling under professional medical control, State-sponsored rationalization and ef- ficiency plannin and private-profit concerns such as insurance companies and nurs- ing homes. I n t h s way, professionalism and capitalism coincide in their efforts to further their own efforts, while stemming community control in favor of social con- trol.

Nassi (1978) has written that the only real community control has been by the wealthy and professionals, and that perhaps it is necessary to begin refocusing our questions: “The noncontroversial nature of community participation by the wealthy is to be contrasted with the highly controversial nature of participation by the greater com- munity to include the poor and ethnic minorities.”

In a survey of the literature, Nassi finds that most ongoing examples of participa- tion are of an elitist or advisory nature, with no real decision-making power. While some of the studies cited by Nassi (Holton, New, & Hessler, 1973; Health Policy Advisory Center, 1972; Chu & Trotter, 1974) covered only a small number of CMHCs, it is infor- mative to look at a later study by Mazade and Sheets (1975) that surveyed 130 mental health boards in two states and found them to be generally of the elitist type and very un- aware of their communities’ problems.

Nassi’s discussion of the major obstacles to community control cites professionalism, by which professionals monopolize their differential possession of technical knowledge, manipulate information, and claim that only the professionals are capable of evaluating themselves. Second, there is the problem of mental health ideology, which typically blames the victim, rather than focusing attention on the sociopolitical in- stitutions which lie at the heart of the problem. Third, the mental health establishment acts in a self-serving manner by rejecting, co-opting, or giving lip service to reform while at the same time acting to stem real reform. Surprisingly, Nassi limits her discussion of the mental health establishment to the local level, when the state and especially the federal establishments are far more central in this process.

The worst situation deriving from professionals’ total rejection of popular consumer control, Nassi asserts, is the Chilean Medical Association’s active and key involvement in the 1973 fascist coup against the Unidad Popular government, Chilean physicians had spent the duration of the Allende regime in bitter attacks on the national health service

*The author would like to warmly thank Andy Barlow for his very helpful reading of a prior draft. Send reprint requests to author, Department of Sociology, University of Massachusetts/Boston, Harbor Campus, Boston, Massachusetts 02125.

384

COMMUNITY CONTROL OF MENTAL HEALTH SERVICES 385

and the workers’ and peasants’ popular control activities. Nassi’s analysis im- plies - even demands - that we go beyond merely a critique of the professionals. Even though professionalism is a major obstacle (and professionalism ultimately includes, in whole or part, Nassi’s other two obstacles - mental health ideology and the local men- tal health power structure), there is a more profound barrier to community control. What Nassi points out in raising the matter of Chilean physicians’ fascist politics is not simply a matter of professionals holding ultra-reactionary politics. Rather, it is a central part of an open ruling class attack on the working class, peasantry, and some sectors of the middle strata. The brutal genocide of the Pinochet regime, brought to power with the support of the CIA and ITT, places in sharp perspective the fact that capitalist society’s basic class antagonisms’ are the blocks upon which professionalism is constructed. Professional Dominance and Psychiatric Expansionism

Professional dominance involves a profession’s monopoly of skills, the right and power to evaluate their own performance, and some degree of public acceptance of that situation. But, above all, it depends on the profession securing an alliance with the government, usually through the medium of professional organizations (e.g. American Medical Association, American Psychiatric Association, American Psychological Association) and professionals’ institutional affiliations (especially the more influential medical complexes, universities, research institutes, and foundations). Such an alliance provides for a legal monopoly of practice, control of education and licensing, special access to government and foundation funding, and varying degrees of control over the financing apparatus (private insurance, noncommerical insurance, and government third-party payments).

The acceptance of class, race, and sex biases by leading sectors of the mental health professions leads them to act in accordance with the status quo so as to augment their power, autonomy, prestige, and income. Further, they often generate demand so as to obtain expanded markets for their services. This is done by employing the above- mentioned mechanisms of State power (among other ways, such as ‘public education’), which tend to serve ruling class interests. By reinforcing the existing social biases and by seeking to exploit markets as they do - either in private practice or on salary - professionals often reinforce existing class relations. This, in turn, supports the general capitalist dominance, even if the professionals do not support specific capitalist views on all matters.

The whole growth of post-World War I1 mental health policy in the U. S. is one of the best examples of such professional dominance. The federal government, and later the state governments which followed it, provided the core from which the mental health lobby2 could achieve the country’s first nationwide program of mental health planning and service delivery.

‘This class antagonism comprises a cluster - a “triple jeopardy” - of race, class, and sex oppression. Key studies linking each of those areas to mental health and illness are Hollingshead and Redlich (1958), Sillen and Thomas (1972), and Chesler (1973).

% brief, the mental health lobby consists of those parties having basic involvement in mental health planning and services on the particularly national level. Among the original segments of the lobby, as well as some formed subsequent to the initial phase of planning, are American Psychiatric Association, American Psychological Association, National Institute of Mental Health, key officials of state mental health depart- ments, the National Association for Mental Health, National Committee Against Mental Illness, National Council of Community Mental Health Centers, National Association of State Mental Health Program Directors, foundations and philanthropists, and political and congressional leaders involved in mental health planning and legislation.

386 PHIL BROWN

In a short while, this growth led to the increasing expansion of psychiatric power to cover an incredibly large array of nonpsychiatric problems: crime, delinquency, educa- tion, racism, local political affairs, police matters, welfare functions, and the like. This psychiatric evangelism is presented as ‘therapeutic’ and ‘preventive,’ rather than as ex- amples of massive governmental and professional intervention into many areas of daily life. Based on notions of ‘value-free’ science and medicine, this evangelistic aspect of community mental health ideology set itself up as a major social planning apparatus by virture of some supposedly special knowledge about the inner secrets and workings of human behavior. The function of that knowledge, however, is to support and be sup- ported by the class society, since it serves as an ideology of that society.

One part of that ideology which has been widely applied is the notion of the “mental health movement,” i.e., mental health reform and expansion as a social movement. While many humanitarian students and professionals may have been motivated by a desire to help people in distress, this “movement” status confused the issue since it in- volved a top-down model of change in which professionals would ‘organize’ client com- munities. This is an impossible task, particularly in terms of the mental health ideology of social movement status. Despite many professional claims, the mental health ‘move- ment’ is not a movement akin to the civil rights or anti-Vietnam War movement. Take, for instance, a recent community mental health text (Bloom, 1975) which discusses com- munity mental health as “part of a larger social revolution,’’ one part of which was a “planning revolution that now includes highway planning, general hospital construction planning, urban redevelopment, and other projects.” Actually, that sounds like a major counterrevolution when one counts the hundreds of thousands of poor and working class people displaced by needless highways, hospitals’ parking lots, profitable urban ‘renewal,’ and the like. In fact, even CMHCs have been built on the ruins of demolished working class neighborhoods. Such movement status, then, is only a vehicle for the crea- tion of consumer demand of more mental health services, and a screen for harmful ac- tivities. The Psychologizing of Politics and Economics

A contradictory element of ‘movement’ status is that the mental health planners saw their movement as a partly political program in that it sought to ameliorate certain social problems, yet they ignored the potential of real political opposition on the left and/or right. In other words, they expected only professional opposition. Thus, as Musto (1975) remarks, they often saw their opponents as ignorant at best, and mentally ill at worst. This dangerous tendency to label political opponents as mentally ill rather than dealing with the actual opposition is a self-serving worldview. Psychohistory, one recent example of this tendency (cf. Lifton, 1975; Mazlish, 1971), focuses on psychopathology in political leaders such as Nixon and Hitler, rather than on the real political and economic forces represented by those leaders.

An extension of this outlook can be observed in psychological explanations of 1960s black liberation, antiwar, and student movements. In response to the 1967 Detroit ghetto rebellion, Vernon Mark and Frank Ervin suggested that innate violence was the cause of the riots, rather than any political-economic explanation involving poverty, racism, police brutality, and unemployment. Their answer: massive screening of ghetto residents to select candidates for preventive psychosurgery. Bruno Bettleheim, noted psychologist, felt similarly about campus protests over university war research. Rather than argue politically with protestors, Bettleheim labeled them as pathological students acting out unresolved Oedipal complexes.

COMMUNITY CONTROL OF MENTAL HEALTH SERVICES 387

Not only did the mental health planners psychologize their target populations, but they also psychologized the psychiatric work force. In the late 1950s, a series of articles appeared (Gilbert & Levinson, 1957a; Gilbert & Levinson, 1957b; Pine & Levinson, 1957) which sought to identify “humanism” and “custodialism” in the mental health work force, ostensibly to provide more humanistic care for mental patients in the new era of community mental health. “Custodialism,” especially in aides, was a viewpoint which saw mental illness as biological in origin, patients as irrational and dangerous, and psy- chiatrists as rigid authority figures. “Humanism” posed the opposite poles: psy- chodynamic origins of mental disorders, patients as understandable, and psychiatrists as having rational authority based on training and experience. Further, custodial aides saw their jobs as dead-end, while humanistic aides did not. Not surprisingly, aides scored high on custodialism and psychiatrists on humanism. What this meant to the researchers and planners was that the working class aides had the wrong attitude toward psychiatry and would have to be retrained, or more likely, replaced by more humanistic people. Ac- tually, whatever irrationality and dangerousness the aides perceived was because they had been taught for years that mental illness was irrational to anyone other than psy- chiatrists, The aides believed as they did because they had to believe it for job security. Further, psychiatrists did have arbitrary power. They were, for instance, the only people with the power to devise new theories of mental illness and then expect everyone to agree with them. Even though aides had always provided the front-line service and the primary therapeutic contact, this was ignored by the psychiatrists whose incomes were many times higher and whose jobs were definitely secure.

One result of these attitudes has been the driving out of working class aides, to be replaced by college graduates who are taking a few years off before proceeding to graduate or professional school. These young people tend to express themselves in terms familiar to the professionals since they come from similar backgrounds. They seem to have boundless optimism, since they will not likely stay in their jobs too long. And, many of them are in large agreement with at least certain elements of the mental health professionalism that some of them may shortly be part of. Professionals who engineer such changes in the work force are essentially acting against the interests of the working class, while covering that up with theories of “humanism.” The Watershed of Community Control Mythology

Given such backgrounds, it was hard to believe NIMH’s claim that the “mental health revolution’’ was going to end the “two-class’ system of mental health care. Such a project was ultimately impossible due to: 1) the class, race, and sex biases of most professionals; and 2) the fact that society in the U. S. is a sharply polarized class society. What could community control mean in that context, particularly when it was mandated from above?

CMHCs have continued the class-based system of mental health treatment. NIMH contends that the centers are serving more and more people in low-income areas, but that does not mean that they are actually serving poor and working class people. Reported figures are usually for all residents within a catchment area having a certain median in- come (for 1973, low-income areas had median incomes of $7,987 or less). NIMH’s latest Statistical Note on CMHC additions lists many variables, but does not include clients in- come (Redick, 1976). Thus, claims to be serving poor people are not proven. I f the centers were really serving poor people, adequate data would be provided to prove that point.

388 PHIL BROWN

Looking at paraprofessionals, one of the main “community” facets of the new model, one finds that even avid proponents of CMHCs (Bloom, 1975) note that paraprofessionals tend to treat low-income clients while white professionals cater to white patients from higher brackets. Lang (1975) found that paraprofessionals were often used as deception, to obtain information unavailable to professionals. Further, the community workers were the only clinical staff not allowed to select their own patients.

Catchment areas are another key element of community mental health. In fact, community is often defined as merely the geographical entity of a catchment area. These areas do not, in any sense, reflect real communities. At their worst, catchment areas are sometimes gerrymandered for racist purposes. In Pontiac, Michigan, the North Oakland CMHC‘s area is arranged so that the actual facility is located in the city of Pontiac, yet excludes from its jurisdiction the poor and black residents of that very city. (Health Policy Advisory Center, 1972).

CMHCs have also functioned to provide teaching material for professionals. NIMH training funds’ massive influx in the 1960s and early 1970s were very important to CMHC staffing. These funds, either in CMHCs or other facilities, tended to train psy- chiatrists and many psychologists who would soon leave to enter private practice where they would definitely serve a significantly higher class clientele than they did while train- ing.

The major critiques of the CMHC program (Health Policy Advisory Center, 1972; Chu & Trotter, 1974; General Accounting Office, 1974) leave us with a pessimistic pic- ture of the community mental health “movement.” Perhaps the watershed of faith in community control was the famous Lincoln Hospital struggle in 1969. Lincoln Hospital Mental Health Services (LHMHS) was a project of Yeshiva University’s Albert Einstein Medical School, the nucleus of a medical center which dominates most of the Bronx’ medical care (Ehrenreich & Ehrenreich, 1970; Kotelchuck, 1976). Popular demands for storefront satellite clinics had been successful for a while, but when LHMHS’s Office of Economic Opportunity grant ran out, they obtained CMHC funding, which meant a total program change. The storefronts were to be phased out, and their community political action terminated. One specific directive against tenant organizing was prompted by the fact that a targeted landlord was a large Yeshiva contributor. Elections for a representative community board were cancelled by Yeshiva around the same time. Then, when several third world paraprofessionals were fired for disciplinary reasons, the revolt broke out in the CMHC which NIMH had designated as one of the nation’s eight model CMHCs. In March 1969, nearly 200 mental health workers, professionals, and community supporters occupied the mental health center, demanding the return of previous social programs and of popular control (Ehrenreich & Ehrenreich, 1970; Chu & Trotter, 1974). Hospital and university response was brutal: the administration called the police in, who proceeded to wound and arrest dozens of people. Demonstrations against this attack continued for weeks, and although they failed in this one campaign, the Lin- coln activists had conducted the first foray in a long history of other community control struggles at Lincoln Hospital (Reverby & Handleman, 1972).

After Lincoln, few persons continued to believe that CMHCs could involve real community control, at least over issues which the community felt to be central. And, NIMH and other mental health officials ceased encouraging such beliefs. Nevertheless, mental health practitioners and planners have not so quickly abandoned the ideology of community, as any casual perusal of the literature will demonstrate. But in the present

COMMUNITY CONTROL OF MENTAL HEALTH SERVICES 389

period, to adhere to myths of community mental health, especially the one about com- munity control, is to miss the political-economic realities of mental health policy in the u. s. Basic Forces Shaping Mental Health Policy

In looking at the results of post-war mental health policy, one finds that community mental health has taken place independent of the deinstitutionalization of state hospital patients. One result of this chaotic development is that nursing and boarding homes are now the single largest place of mental health ‘care’ and expenditure. Sheer numbers are shocking: some 900,000 mentally disabled persons (of all types) live in nursing and boarding homes, greatly outnumbering the state hospital population of under 200,000 (National Institute of Mental Health, 1976). Increasingly, mental patients are dis- charged directly to these homes, which in 1974 accounted for $4,242,905,000, or 29.2% of total US direct mental health costs; state and county mental hospitals made up 19%, and CMHCs 4.2% (Levine 8c Willner, 1976).

These homes’ terrible conditions and lack of therapeutic or rehabilitative care have been well-documented by the Senate Subcommittee on Long Term Care (1976), and in- creasingly have attracted much attention in the mental health field. But despite the Senate hearings’ testimony, there has been hardly any attention paid to the structural bases of the society in which entrepreneurs have made great profit out of the uncoor- dinated mental health policy. Not only can a person like Daniel Slader earn a $185,000 annual profit from his Melbourne Nursing Homes in Chicago by, among other things, spending 544 a day per patient for food, but monopolizing tendencies are growing rapidly. One hundred and six corporations took one-third of the industry’s 1973 revenue of $3.2 billion (U. S. Senate, 1976). Some of these are chains of many dozens of homes, some are part of proprietary hospital conglomerates, and others are subsidiaries of monopoly corporations such as Holiday Inn’s Medicenters Division (Chase, 1972; Santeistevan, 1976; U. S. Senate, 1976).

While state governments have managed to shed some state hospital costs by massive deinstitutionalization, the federal government has picked up most of that cost. Medicaid, for example, is one of the largest purchasers of psychiatric services. In terms of all nurs- ing homes, Medicaid pays around 50% of the $8.5 billion tab (U. S. Senate, 1976, xii) much of this for ex-patients. Social Security’s Supplemental Security Income (SSI), and to a smaller extent Medicare, also pay much of the nation’s mental health costs. These federal programs, with varying percentages of state co-payments, are very restrictive as to what facilities are eligible. Unless recipients are under 21 or over 65, Medicaid will not pay for treatment in psychiatric facilities. In no cases are public facilities eligible for Medicaid, Medicare, or SSI. Neither Medicaid nor Medicare cover any significant amount of private or clinic outpatient care. The result is a system which favors private psychiatric hospitals, private general hospital psychiatric wards, and profit-making nurs- ing and boarding homes.

In order to take advantage of the wealth of third-party payments, general hospitals have greatly expanded their psychiatric wards in recent years. From 1964 to 1970, they increased from 538 to 766 nationwide, a 42.4% increase. Virtually all of this increase was in private hospitals whose psychiatric wards increased 71.9% as compared to a 2.2% in- crease for public hospitals. From 1971 to 1975, inpatients in private hospital psychiatric wards increased 32.1% while falling 34.5% in public hospital psychiatric wards (NIMH, 1972; NIMH, 1977).

390 PHIL BROWN

Thus, government payments are providing guaranteed profits to increasing numbers of private sector interests, In health care overall, Medicare and Medicaid account for an abnormally large rise in health costs since those programs were implemented in 1966 (Hodgson, 1976). Given the increasing medical dominance over psychiatry, this rise holds true for mental health services.

Alongside the substantial government payments are the increasing private and non- commercial insurance payments for mental health care. The insurers’ restrictions on coverage are often similar to the government’s, providing for reliance on private facilities. I n 1973, health insurance grossed $29 billion, nearly half of the total insurance company receipts in the U. S. for all forms of insurance (Navarro, 1976). Health in- surance is rapidly moving into mental health, a move which NIMH and most mental health planners see as the wave of the future that will enable mental health care to con- tinue in the face of cutbacks in direct government appropriations (NIMH, 1976). Health insurance is a central part of the direct profit-making sector of the medical-industrial complex, either in the form of direct profit (private, profit-making insurers) or in the form of general financing apparatus (Blue Cross). The medical-industrial complex has been one of the U. S. economy’s boom sectors in the last decade, and under some up- coming form of national health insurance, private interests will undoubtedly augment their already high profits.

In such ways, the seeming chaos of current policy consists of more than just bureaucratic and professional errors or intentions. As Andrew Scull (1977) shows in his book, Decarceration, the State is “socializing” more and more of the costs of capitalist reproduction. The social costs of an expanding surplus population of unemployed, un- deremployed, and social victims cannot be born entirely by the private sector, so the government takes over some of the burden. This phenomenon increases with the increase in monopoly tendencies in the society, since those tendencies both increase the surplus population and also produce more serious mental illness and other forms of breakdown.

Like the federal government, the state governments take on many social overhead expenses which benefit capitalism. Funding for this comes from increased taxes and cut- backs in social services, both of which primarily affect the working class and lower mid- dle class. Furthermore, poor and working class people are demanding more of their share of the social wealth, and the government cannot absorb these costs while still serving private interests. Thus, the state governments suffer “fiscal crises,” which they attempt to pass on to the federal government. Deinstitutionalization appears to be a successful way for states to pass on mental health costs to the federal and local governments as welfare costs. But such savings are short-term since welfare costs tend to rise as uncon- trollably as mental health costs. They may even rise faster, since there are no watchdog committees on nursing and boarding home costs, and since the institutional population of the homes is growing. Thus, it is becoming apparent that “community care” hasn’t delivered the great cost savings originally expected (Kirk & Therrien, 1975). The fiscal crisis is a more generalized political-economic crisis at the national and international levels, and cannot be solved by cost transfers. Political Economy and Professionalism

These overall political-economic developments allow for a nearly unhindered professionalism; the two go hand in hand. As academic-based medicine takes over more and more of health care, professional power increases. Further, the professionals’ power leads them to insure its maintenance by supporting positions which keep the medical

COMMUNITY C O N T R O L OF MENTAL HEALTH SERVICES 391

organization intact (e.g., urban renewal to expand hospitals, closing down of community hospitals, regionalization of maternity wards, cutbacks in general outpatient clinics, layoffs of health workers). The medical organizations are also interlocked with insurance companies, drug and supply companies, and banks. Thus, professional power and monopoly capital find themselves on the same side, even if for somewhat different avowed reasons. Additionally, mental health has been increasingly taken over by the medical industry through insurance, government reimbursements, and cost-benefit health planning (e.g., health systems agencies, health maintenance organizations, professional standards review organizations). The psychiatric profession is supportive of much of this development, since they need a more stable professional system. And, to the extent that clinical psychologists are allowed in by the medical profession, government, and insurance companies, they too will join the movement toward more centralized and standardized service^.^

Given these structural bases, why would one expect a well-connected psy- chiatrist - whose world is linked up with a wealthy private clientele, a prestigious hospital post, and a medical school professorship - to be supportive of poor and work- ing class people pressuring for community control? The professional might give different arguments against community control than would an insurance executive or a mental health official, but they are all protecting the same interlocked system. Thus, psychiatric expansionism combines with the medical-industrial complex and the government to favor control of the community and social control, rather than actual community con- trol, despite the efforts of some very well-intentioned practitioners and planners.

Professionals, like other people, tend not to struggle against their own interests. Therefore, one should not expect the elite levels of the mental health field to support real community control, one aspect of which would be their taking some leadership and direc- tion from their client populations. However, there is an internal stratification in the men- tal health field. Nonpsychiatrist mental health staff - aides, nurses, paraprofessionals, community workers, occupational therapists, even some psychologists - are potential supporters of community control since community control struggles target the same op- ponent: the top psychiatric and psychological leadership and administration of the facility. Many mental health staff are increasingly powerless in the midst of standar- dized, bureaucratized, and centralized services. They often seek more job control and respect, including the ability to better serve clients. That perspective obviously clashes with many administrators’ and upper professionals’ push for efficiency, cost-benefit ser- vices, and impersonality. In such situations, one finds possible locations of support for community control struggles such as Lincoln Hospital, for mental health workers fighting to protect their eroding jobs, and for mental patients rights activists pressing for changes in the legal and medical/psychiatric structure. But ultimately, there can be little community control in a society where social class is so strongly defended and where true communities hardly exist.

SClinical psychologists are being partially allowed in due to the phenomenal growth of their practice and professional power in the last few decades. I t would be very difficult to continue to exclude them from eligibility to collect third-party reimbursements, given their fundamental role in mental health services. At any rate, restrictive licensing laws will limit the number of eligible psychologists. And, as an extra incentive, they are reimbursed and salaried at far lower cost than psychiatrists.

392 PHIL BROWN

REFERENCES

BLOOM, B. L. CHESLER, P. CHU, F. D., & TROTTER, S. EHRENREICH, B., & EHRENREICH, J. (Eds.). The American health empire: Power, projts, and politics.

New York: Vintage, 1970. GENERAL ACCOUNTING OFFICE. Need for more effective management of community mental health

centers program. Washington, D. C.: Government Printing Office, 1974. GILBERT, D. C., & LEVINSON, D. J. “Custodialism” and “humanism” in mental hospital structure and

in staff ideology. In M. Greenblatt, D. Levinson, and R. H. Williams, (Eds.), The patient and the mental hospital. Glencoe, Ill.: Free Press, 1957.

Role performance, ideology, and personality in mental hospital aides. In M. Greenblatt, D. Levinson, & R. H. Williams, (Eds.), The patient and the mental hospital. Glencoe, 111.: Free Press, 1957.

HEALTH POLICY ADVISORY CENTER. Evaluation of community involvement in community mental health centers. New York: 1972. (NTIS No. PB 211-267).

HOLLINGSHEAD, A. B., & REDLICH, F. C . Social class and mental illness. New York: Wiley, 1958. HOLTON, W. E., NEW, P. K., & HESSLER, R. M. Citizen participation and conflict. Administration

in Mental Illness, 1973, Fall, 96-103. KIRK, S. A., & THERRIEN, M. E. Community mental health myths and the fate of former hospitalized

patients. Psychiatry, 1975, 38, 209-217. KOTELCHUCK, D. (Ed.). Prognosis negative: Crisis in the health care system. New York: Vintage, 1976. LANG, C. Professional stratification and psychiatric ideology in a community mental health unit. Un-

LEVINE, D. S., & WILLNER, S. G. The cost of mental illness, 1974. National Institute of Mental Health

LIFTON, R. J. (Ed.). Explorations in psychohistory. New York: Simon & Schuster, 1975. MAZADE, N. A., & SHEETS, J. L. Changing roles and structures of mental health boards. In J. Zusman &

E. F. Bertsch, (Eds.), The future role of the state hospital. Lexington, Mass.: Lexington Books, 1975. MAZLISH, B. (Ed.). Psychoanalysis and history. New York: Grosset, 1971. MUSTO, D. Whatever happened to community mental health? The Public Interest, 1975, Spring, 53-79. NASSI, A. J. Community control or control of the community? The case of the community mental health

center. Journal of Community Psychology, 1978, 6, 3-15. NATIONAL INSTITUTE OF MENTAL HEALTH. Psychiatric services in general hospitals. Mental Health

Facilities Report Series A., No. 11. Washington, D. C.: Government Printing Office, 1972. NATIONAL INSTITUTE OF MENTAL HEALTH. The financing, utilization, and qualify of mental health

care in the United States: A draft report. Washington, D. C.: Government Printing Office, 1976. NATIONAL INSTITUTE OF MENTAL HEALTH. Changes in numbers of additions to mental health facilities

by modality, United States, 1971 and 1975. Division of Biometry and Epidemiology Memorandum #lo. Rockville, Md.: National Institute of Mental Health, 1977.

Community mental health: A general introduction. Monterey, Cal.: Brooks/Cole, 1975.

The madness establishment. New York: Grossman, 1974. Women and madness. New York: Avon Books, 1973.

GILBERT, D. C., & LEVINSON, D. J.

published Ph.D. dissertation, Brandeis University, 1975.

Statistical Note No. 125. Washington, D. C.: Government Printing Office, 1976.

NAVARRO, V. PINE, F., & LEVINSON, D. J.

Medicine under capitalism. New York: Prodist, 1976. Two patterns of ideology, role performance, and personality among mental

hospital aides. In M. Greenblatt, D. Levinson, & R. H. Williams, (Eds.), Thepatient and the mental hospital. Glencoe, 111.: Free Press, 1957.

REDICK, R. W. Addition rafes to federally funded community mental health centers, United States, 1973. National Institute of Mental Health Statistical Note No. 126. Washington, D. C.: Government Printing Office, 1976.

Institutional organizing: The emancipation of Lincoln. Health-PAC Bulletin, 1972, No. 37, 4-8.

Deinstitutionalization: Out of their beds and into the streets. Washington, D. C.: American Federation of State, County, and Municipal Employees, 1976.

Decarceration - Community treatment and the deviant: A radical view. Englewood Cliffs, N . J.: Prentice-Hall, 1977.

REVERBY, S., & HANDLEMAN, M.

SANTIESTEVAN, H.

SCULL, A. T.

SILLEN, S., & THOMAS, A. U. S. SENATE, SUBCOMMITTEE ON LONG-TERM CARE.

Racism and psychiatry. New York: Brunner/Mazel, 1972. The role of nursing homes in caring for discharged

mental patients (And the birth of a for-profit boarding home industry). Washington, D. C.: Government Printing Office, 1976.